Brugada-like precordial ST elevation on ECG by anterior mediastinal infective mass lesion.

Several causes are known to induce the right precordial ST elevation mimicking Brugada syndrome. Right ventricular outflow area is assumed to be responsible for such ECG changes. We experienced a case of anterior mediastinal infective mass lesion with a Brugada-like ECG. A 52-year-old female, who has pulmonary stenosis and recurrent episodes of right ventricular heart failure, complained of high fever, abdominal discomfort, and edema. On physical examination, jugular vein dilation, hepatomegaly, and facial and leg edema were noted. Leucocytosis was also noted on blood examination. An ECG showed right ventricular hypertrophy, incomplete right bundle branch block pattern and marked ST elevation on precordial leads mimicking Brugada syndrome. Magnetic resonance imaging revealed an abnormal mass shadow located on the anterior mediastinum and compressing the right ventricle (Figure 1A). Trans-thoracic echocardiography also showed the high echogenic mass lesion at the anterior side of right ventricle and the vicinity of pulmonary valve. After treatment with antibiotics, the mass lesion gradually shrunk. Concomitantly, the ST elevation disappeared with improvement of inflammatory markers (Figure 1B). The symptoms suggesting right ventricular failure were also ameliorated. The mechanism of Brugada-like ST elevation in this patient was considered to be compression, by the abnormal infective mass, of the right ventricular outflow tract with/without focal pericardial inflammation.


INTRODUCTION
Bordetella pertussis is a Gram-negative bacterium that causes a highly contagious respiratory disease, pertussis or whooping cough. Despite extensive immunization, the disease has remained endemic causing epidemics every 3 to 5 years. A resurgence of pertussis has been observed in USA, Europe, Canada, Australia and Asia [2][3][4][5][6][7][8][9][10]. In Finland, a whole-cell pertussis vaccine was introduced in 1952. Although the vaccination coverage of four doses has been high, pertussis remains endemic and the incidence of pertussis has increased since last decade [6].
For more effective vaccination programs to prevent pertussis, it is important to understand pathogenesis and transmission of B. pertussis, to monitor changes in bacterial populations and to study impact of the changes on the prevention and incidence of disease. Different typing methods have been developed and applied for studying molecular epidemiology of B. pertussis, such as serotyping of fimbriae (Fim), genotyping of virulence genes, pulsed-field gel electrophoresis (PFGE) and multi-locus variable number of tandem repeats (MLVA) analysis [4,6,9,[11][12][13][14][15][16][17][18][19][20][21]. These studies revealed that the B. pertussis population is dynamic and that antigenic divergence has occurred with respect to pertussis toxin (Ptx), pertactin (Prn), Fim2 and Fim3 between the vaccine strains and circulating isolates. Further, it was observed that epidemics in many countries were associated with clonal expansion of strains.
Genome sequencing offers a global view of the genetic content of pathogenic bacteria. Of the nine Bordetella species, annotated genome sequences of B. pertussis, B. parapertussis, B. bronchiseptica and B. avium have been recently published [1,22]. The sequenced B. pertussis strain Tohama I, originally isolated in Japan in 1954, is considered a reference strain and used for the production of acellular pertussis vaccines. The genome of B. pertussis has 3,816 ORFs [1]. A notable feature is the high load of insertion sequence (IS) elements and relatively high content (9.4%) of pseudogenes [1].
Based on the available sequence, we developed an oligonucleotide (70-mer) microarray for comparative genomic analysis of B. pertussis strains. Our aim was to study the evolution and molecular epidemiology of B. pertussis strains isolated in Finland where the whole-cell vaccine has been used for more than 50 years. Insight into B. pertussis capacity to adapt to vaccine-induced immunity is important for understanding the current epidemiology of pertussis in vaccinated populations. In addition to the historical perspective, the emphasis of strain selection was on recent isolates causing nationwide epidemics. The microarray results were compared with those obtained by standardized typing methods.

Bacterial strains and culture conditions
Bacterial isolates were selected from the B. pertussis strain collection from the Pertussis Reference Laboratory of the National Public Health Institute, Turku, Finland. The selection criteria included the time and geographic location of isolation, and their serotypes, genotypes and PFGE profiles [6,13,21]. A total of 20 clinical isolates from 1953 to 2004 together with two Finnish vaccine strains and two international reference strains, Tohama I, isolated in Japan in 1954 and 18323, isolated in USA in 1946 were included (Table 1). Finnish vaccine strain 18530 was obtained from USA and has been used since 1962, and strain 1772 was obtained from UK and was added to the vaccine in 1976. The 50year period was covered in a way that from 1950's to 1980's one to two strains represented each decade and from 1991 onwards strains were selected according to incidence peaks observed in the whole country (Table 1). We have previously shown that Finnish B. pertussis population was dynamic and has continuously evolved [6,13,21]. Therefore, the strains selected for the present study were representative of the most prevalent PFGE profiles from 1953 to 2004. To avoid the influence of local outbreaks, isolates from at least two geographic locations were selected. All strains were isolated from children younger than 12 years.
Bacteria stored in 270uC were recultured on Charcoal agar (Oxoid Ltd, Basingstoke, England) with 10% defibrinated sheep blood. The plates were incubated at 35-36uC for 3 days. Bacteria were harvested and suspended in distilled water. Prior to DNA isolation, the concentration of bacterial suspension was adjusted to 2610 9 cells/ml. DNA isolation, digestion and hybridization B. pertussis DNA was isolated with GenElute TM Bacterial Genomic DNA Kit (Sigma-Aldrich Inc., St. Louis, USA) and digested with Sma I (10 U/mg DNA, New England Biolabs, Ipswich, USA) according to the instructions of the labeling kit BioPrimeHArray CGH Genomic Labeling System (Invitrogen Life Technologies, Carlsbad, USA). The quality of digested DNA was examined by gel electrophoresis. Digested and undigested DNA was compared as the starting material for hybridization and no effect of the DNA treatment on identification of absent genes was found. The existence of restriction site (CCCGGG) of SmaI was searched into BpSR147 Range of the lost genes in loci 1-4 is BP0910A-BP0934, BP1135-BP1141, BP1948-BP1966, and BP2088-BP2103, respectively. (+) and (2) indicates presence or absence of the locus.
Three genes in the locus were lost (BP0910A-BP0912).

3.
Strain used for the production of whole cell vaccine in Finland since 1962 and obtained from USA.
DNA sequences of the 3,582 70-mer oligonucleotides used in the microarray (see section of the oligonucleotide-based microarray). Only 55 (1.5%) oligonucleotides were found to possess the restriction site. Of them, 48 belonged to the genes identified as present, five as duplicated, and two as absent, indicating that the existence of restriction sites on oligonucleotides did not affect the identification of absent or duplicated genes in the microarray. To avoid the possible effect of length and conformation of long chromosomal DNA on labelling, the digested DNA was used for all experiments.
We next compared the amount of DNA (range: 2 to 8 mg) used as the starting material and found no effect on identification of absent genes. The amount of 4 mg was thus chosen for all experiments. The 4 mg of digested DNA of the Tohama I strain used as reference strain were labeled with Cy 3 and that of testing strain with Cy 5 (Amersham Biosciences UK Limited, Buckinghamshire, England) according to the protocol of BioPrime-HArray CGH Genomic Labeling System (Invitrogen Life Technologies, Carlsbad, USA). The labeled DNA was purified with the purification kit of the same manufacturer and then combined. The concentrations of Cy3 and Cy5 were measured with ND-1000 Spectrophotometer (NanoDrop Technologies, Wilmington, USA).
The volume of labeled DNA was reduced below 15.7 ml in vacuum centrifuge, and 2.5 ml of yeast tRNA (10 mg/ml, Invitrogen Life Technologies, Carlsbad, USA), 4.3 ml of 206SSC (16SSC was 8.8 g/l NaCl and 4.4 g/l trisodiumcitrate) and 0.8 ml of 10% SDS were added. After denaturation at 100uC for 3 min, 1.7 ml of 106Blocking Solution from DIG-Wash and Block Buffer set-kit (Roche, Mannheim, Germany) was added. The final volume for hybridization was adjusted with water to 25 ml. Before hybridization, slides were fixed by UV-cross linking with 90 mJ cm 22 , washed for 1 min in 0.1% of SDS and 2 min in water to remove residual salt, and incubated at 50uC for 30 min in BSA solution containing 1% of BSA fraction V, 26SSC and 0.1% of SDS to block nonspecific binding. The slides were further washed in 26SSC for 3 min and then in 0.26SSC for 3 min.
Hybridization was conducted under 22625 mm LifterSlip TM coverslip (Erie Scientific Company, Portsmouth, USA) in hybridization chamber at 65uC for 16 h. To control humidity inside the hybridization chamber, a strip of thin paper, humidified with approximately 100 ml of 3.46SSC, was placed under the slide. After hybridization slides were washed at 65uC for 10 min with 16SSC and 0.1% of SDS. The following washes were conducted at room temperature for 10 min with 0.56SSC and 0.01% SDS, and for 3 min and 1 min with 0.16SSC. Slides were dried in slide centrifuge and scanned with ScanArray H5000 (PerkinElmer, Waltham, USA).

Oligonucleotide-based microarray
The oligonucleotides used in the microarray were designed in collaboration with Operon Biotechnologies GmbH (Cologne, Germany), and an Array-Ready Oligo Set TM was purchased from the Operon. The set of 3,582 70-mer oligonucleotides, where one oligonucleotide corresponded to one gene, covered 94% of 3,816 ORFs of B. pertussis Tohama I [1]. Lyophilized oligonucleotides were dissolved in 50% of DMSO and 26SSC to the concentration of 20mM. The oligonucleotides were spotted on UltraGaps TM coated slides (Corning Life Sciences, Acton, USA) with ''R-ray'', an in-house spotter in the Finnish DNA Microarray Centre, the Centre for Biotechnology, Turku, Finland. Each oligonucleotide was spotted twice. A total of 20 randomized negative controls with no match to DNA of B. pertussis Tohama I were spotted in 8 separate spots to control non-specific binding. Contamination of printing tips and non-specific binding of DNA to slide surface was controlled by spotting water and buffer in 244 spots. Oligonucleotides representing 12 house-keeping genes of B. pertussis were spotted 10 times and used as positive controls to monitor the intraarray variation of the hybridization.

Image processing, data analysis and statistical testing
Image processing was made using ScanAlyze program from Michael B. Eisen, (Univerity of California at Berkeley). MA-plot, where mean of intensity (A) is plotted against log-transformed intensity ratio (M) of each spot, was created for classifying the genes present or absent in the testing strain. In the MA-plot, majority of the M-values was centered to zero, and a clearly separated group of genes was formed with low M-values ( Figure 1). As the group was completely separated from the majority, genes included in the group were considered as absent and filtered from the raw data by defining M-value,22. Student's t-test was used to determine the difference in log-ratios between present and absent genes and p-value,0.05 considered the statistically significant.

Confirmation of microarray results with PCR
PCR was used to confirm absent genes of the testing strains identified by microarray. The primers were designed with Primer3 program (Steve Rozen&Helen J. Skaletsky, 2000) on the basis of the two genes which flanked the lost locus or of the two genes located at each end of the lost locus. The sequences of the primers and their target genes were shown in Table S1.
PCR reaction contained 5-50 ng of purified DNA, 200 mM of each dNTP (Promega, Madison, WI, USA), 20 pmol of primers (Sigma Aldrich, Haverhill, UK), 5% DMSO (Merck, Darmstadt, Germany), 16Buffer II, 1.5-3 mM of MgCl 2 , 0.625-2.5 U of AmpliTaq GoldH DNA polymerase (Applied Biosystems, Foster City, USA). The reaction volume was adjusted to 50 ml with Molecular Biology grade water (Eppendorf, Hamburg, Germany). PCR was run in MJ Research PTC 200 Thermal Cycler (Global Medical Instrumentation, Ramsey, USA) with the following protocol: initial denaturation at 95uC for 8 min followed by 30-38 cycles of 30 sec at 94uC, 30 sec to 1 min at 60-62uC and 1 to 3 min at 72uC, and with a final elongation of 5 min at 72uC. The expected size of PCR products was confirmed by gel electrophoresis.

Population of B. pertussis in Finland
More than 400 clinical isolates collected since 1953 have been analyzed by serotyping of Fim, genotyping of pertussis toxin S1 subunit (ptxA) and pertactin (prn), and PFGE [6,13,21]. The strains isolated in 1953-1965 had the same ptxA as the vaccine strains (ptxA2), but a change to ptxA1 occurred in the 1970's (Table 1). During the 1980's, a change from prn1 (the vaccine type) to prn2 (non-vaccine type) was observed. We have previously shown that Finnish B. pertussis population was dynamic and has continuously evolved [6,21].

Performance of the microarray
The oligonucleotide-based microarray was proved to be specific for B. pertussis because no hybridization was observed to randomized negative control spots or water spots. Only marginal variation in the log-ratios was observed when self to self hybridization of DNA of the reference strain and dye swap of DNA of the testing strain were tested.  The 12 housekeeping genes with multiple spots (ten per array) were used for the determination of intra-array variation. The mean of signal intensity ratio (reference strain vs testing strain) ranged from 1.03 to 1.29 and SD from 0.04 to 0.08. The coefficient of variation (CV) was thus 3.37 to 6.76%. Number of absent genes detected was proved to be constant among all the replicate spots. For the determination of inter-array variation, 12 virulence genes present in the testing strain were chosen. Six individual results from three separate arrays were calculated. The mean of signal intensity ratio (reference strain vs testing strain) ranged from 0.99 to 1.40 and SD from 0.04 to 0.09. The CV was thus 3.52 to 8.38%.

Gene loss in B. pertussis strains
Compared with the strain Tohama I, four distinct loci were identified to be absent among the Finnish clinical isolates (Table 1). Relative to the Tohama I chromosome, the number of genes absent was 24 (size: 24 kb) for locus 1 (range: BP0910A-BP0934), seven (8.6 kb) for locus 2 (BP1135-BP1141), 18 (22.7 kb) for locus 3 (BP1948-BP1966), and 16 (17.7 kb) for locus 4 (BP2088-BP2103). However, the four loci were present in the international reference strain 18323 and in the Finnish strain 18530 that has been used for vaccine production since 1962. The other strain, 1772 that was added to the vaccine in 1976, missed the loci 1 and 2. Microarray data has been deposited in Gene Expression Omnibus database (http://www.ncbi.nlm.nih.gov/projects/geo/) and is accessible through accession number GSE8092.
Twenty clinical isolates from the period 1953 to 2004 were analyzed with the microarrays. All three strains analyzed from 1953-1965 missed only one locus (Locus 2). All nine strains analyzed from 1977 to 1996 missed two loci (Loci 1 and 2). Finally, all eight strains analyzed from 1999 to 2004 missed the Loci 1 and 2 in addition to Locus 3. Altogether, the eight strains had 44 absent genes (55.3 kb) in the three different loci. Only the strain PRCB223 which was isolated in 1996 was found to miss Locus 4 ( Table 1). The absence of the four lost loci was confirmed by PCR (Table S2).
Based on genome sequence of the strain Tohama I, all the four absent loci were flanked by IS481.
Although the four absent loci identified among the 20 clinical isolates were present in the reference strain 18323 and the Finnish vaccine strain 18530, additional absent loci were found in the two strains (Dataset S1). Strain 18323 had 196 absent genes identified in 23 loci and the number of genes in each locus ranged from 1 to 33. Of the 23 absent loci, nine were bordered by IS481 and 14 had IS481 adjacent to one side. The Finnish vaccine strain 18530 had 22 absent genes in five different loci and the number of genes in each locus ranged from 1 to 9 (Dataset S1). Of the five loci, four were bordered by IS481 and one had IS481 adjacent to one side. Two loci (BP2627-BP2629 and BP3104-BP3110) were absent in both strains 18323 and 18530. A single gene (BP1225), flanked on one side by IS481, was absent in two clinical strains KKK1277 and 1330, isolated in 1964 and 1965, respectively.

Gene duplication in B. pertussis strain
Of the 20 clinical isolates, one strain KKK1330 was found to have both gene loss and duplication. This strain was isolated in 1965 and had a PFGE profile BpFINR14 distinct from the prevalent profile BpFinR1 found in 1950s and 1960s ( Figure 2, Table 1). The strain missed locus 2 (BP1135-BP1141), whereas two loci were duplicated (i.e. BP1288-BP1442 and BP1481-BP1487). The mean of log-transformed intensity (mean6SD: 0.4860.22) of all the duplicated genes was significantly higher than that of all other present genes (20.3660.26, p,0.001). When the mean of logtransformed intensity was compared between the duplicated genes and all other present genes of the strain KKK1277 isolated in 1964, no significant difference was observed (p = 0.181). IS481 was found adjacent to one side of the locus BP1288-BP1442.

Characteristics of the absent and duplicated genes
In the genome of the strain Tohama I, the percentage of the pseudogenes was 9.4% and average of the GC contents was 67.6% [1]. Of the 65 lost genes identified in 4 different loci, 11 (16.9%) were pseudogenes. The average percentage of pseudogenes is significantly higher than that in the genome of Tohama I strain (chi-squared test, p = 0.047). The corresponding percentages in the loci were 28.6%, 16.7%, 30.8% and 12.5%, respectively. The GC content of the lost genes in each locus was 69.6%, 66.0%, 70.4% and 68.9%, respectively.
A total of 23 functional categories of genes were defined in the Tohama I strain according to the Clusters of Orthologous Groups (COG) [1]. On the basis of the COG, functions of the absent and duplicated genes were compared with that of the strain Tohama I. The number of genes which could be classified into the COG categories are shown in Table 2 and included in the comparison (Figure 3). Of the 23 functional categories of genes, 20 were included in the comparison (Figure 3), because none of the absent or duplicated genes belonged to the categories of RNA processing and modification, cell cycle control and chromatin structure and dynamics.
For the clinical isolates, most notable were high frequencies of absent genes identified in the two functions: inorganic ion transport and metabolism (N = 8) and energy production and conversion (N = 7), representing one third (15/44) of total number of absent genes classified in the COG (Figure 3). The eight genes defined in the function of inorganic ion transport and metabolism included two coding for putative ferric siderophore receptors (BP1138 and BP1962), two for probable inner membrane components of binding-protein-dependent transport system (BP0914 and BP0915), putative exported protein (BP0913), putative signal  There were seven absent genes identified in the function of amino acid transport and metabolism. Of the seven genes, five (BP1948-BP1951 and BP1957) were in locus 3 and two (BP2089 and BP2090) in locus 4. Four genes (BP1950, BP1951, BP2089 and BP2090) were associated with ATP binding cassette (ABC) systems which are responsible for the import and export of a wide variety of molecules across cell membranes of bacteria [23].
Of the five absent genes defined as function unknown, three (BP0923, BP0927 and BP0931) were in locus 1, one (BP1965) in locus 3 and one (BP2103) in locus 4. Four genes coded for putative exported proteins.
We have not observed any absent or duplicated genes that encoded known virulence factors of B. pertussis.
For the vaccine strain 18530, 12 of 22 absent genes were classified in the COG. Of the 12 genes, three belonged to the function for inorganic ion transport and metabolism (Figure 3).
For the reference strain 18323, the missing genes were found in 17 of 20 functional categories. The three categories without missing genes were replication, recombination and repair, cell cycle control, mitosis and meiosis, and nucleotide transport and metabolism (Figure 3).
For the strain KKK1330, the duplicated genes were found in the following functional categories: cell motility, intracellular trafficking and secretion, cell wall/membrane biogenesis, and posttranslational modification, protein turnover, chaperones ( Figure 3). A number of duplicated genes were related to flagella.
Vaccination against pertussis has been introduced in Finland since 1952. The vaccine is produced at the National Public Health Institute, Helsinki, Finland. Strain 18530 has been used since 1962, and strain 1772 was added to the vaccine in 1976. The vaccine has not changed since then, and the vaccination coverage for four doses has been 95%. To better understand the evolution of B. pertussis in immunized populations, an oligonucleotide-based microarray was developed and used for comparative genomic analysis of Finnish strains isolated during a period of 50 years.
Compared with the genome of strain Tohama I, a progressive gene loss was observed among the Finnish clinical strains. Strains  Table 2. doi:10.1371/journal.pone.0000904.g003 isolated in 1950's and 1960's had almost the same gene content as Tohama I, with only seven genes absent. A marked change with the deletion of 24 genes occurred in strains isolated in 1970's, more than 20 years after the vaccination was introduced. The gene content of the strains isolated from the following 20 years remained basically the same. The next major deletion of 18 genes was first detected in strains isolated in 1999, and the gene content of strains isolated throughout the following period remained unchanged. Our data confirmed that B. pertussis population is dynamic and is continuously evolving [6,13,21], suggesting that the bacterium uses gene loss as one strategy for its better adaptation to the highly vaccinated populations. For the future, it is of particular interest to compare our results with those obtained from strains isolated from the same period and from a non-vaccinated population.
Our results obtained from the oligonucleotide-based microarray are consistent with two recent studies of B. pertussis strains using cDNA microarray [24,25]. In addition, we detected a new lost locus that contained 16 genes. However, the lost locus was only found in one among the 20 clinical strains studied.
In agreement with two recent studies, none of genes coding for known virulence factors were found to be lost in the Finnish strains [24,25] , suggesting that virulence factors are critical for B. pertussis to maintain its capability in the transmission and pathogenesis among the human populations. However, changes in known virulence factors pertussis toxin, pertactin and fimbriae coincided with the loss of loci 1 and 3. Since 1977, when the locus 1 was lost, the predominant allele for the gene encoding subunit 1 of pertussis toxin had changed from ptxA2 to ptxA1. Five years after the change in ptxA, pertactin allele shifted from prn1 to prn2. Both alleles are different from the ones in the strains used for Finnish whole cell vaccine. From 1976 to 1998, about 90% of the Finnish isolates expressed Fim2. Since 1999, two nationwide epidemics occurred. In addition to the gene loss of locus 3, the common feature between the strains mainly responsible for the epidemics is the expression of Fim3.
Pseudogenes are usually formed due to frameshift mutation, mutations leading to the insertion of a stop codon or insertion of IS elements [26]. The percentage of the pseudogenes identified among the four lost loci was significantly higher than that in the whole genome, suggesting that the pseudogenes are prone to deletion during the evolution of B. pertussis. In addition, we have observed that the deleted regions have a slightly higher GC content compared with the whole genome (respectively, 68.7% and 67.6%).
Gene loss or genome reduction has been observed in several mammalian pathogens, and IS elements are found to play an important role in this process, in addition to causing chromosomal rearrangements and insertion mutations [27][28][29][30]. A recent study has shown that IS-mediated diversification in Enterococcus faecium strongly contributed to its adaptation to hospital environment [30].During its evolution from B. bronchiseptica like ancestor, B. pertussis has undergone significant gene loss, most likely due to IS elements [1,31]. Three distinct IS elements were found in the genome of B. pertussis Tohama I strain, with the copy number of 238 for IS481, 6 for IS1002 and 17 for IS1663 [1]. Interestingly, all the four loci of lost genes identified among Finnish isolates were flanked by IS481. Furthermore, IS481 was located at least on one side of all loci of lost or duplicated genes detected in this study. Taken together, the results clearly showed that IS481 plays a critical role in the B. pertussis evolution.
It is of particular interest that one third of the lost genes had functions related to inorganic ion transport and metabolism and energy production and conversion. The acquisition of iron, which is an inorganic ion, is critical for pathogenic micro-organisms, because concentration of free iron is limited in the human host [32]. In order to acquire iron, bacterial pathogens produce ironchelating compounds (siderophores). Like B. bronchiseptica, B. pertussis contains an operon encoding the production, export and uptake of the siderophore alcaligin [33,34]. Iron obtained from siderophores is internalized through TonB-dependent outermembrane ferric complex receptors. B. bronchiseptica has 16 genes coding for these receptors, whereas B. pertussis has lost 3 of the genes during its evolution from B. bronchiseptica like ancestor, while one of the remaining was pseudogene [1]. Two of the 12 functional genes coding for the receptors were deleted among the Finnish strains isolated from 1999. These strains were responsible for the nationwide epidemics observed in the country [6,21]. It remains to be shown if these deletions confer a selective advantage of the epidemic-causing strains.
In this study, seven lost genes had functions in amino acid transport and metabolism, four of which encoded ATP binding cassette (ABC) transporter components and were located in two distinct loci. ABC transporters are a large group of proteins which have roles in important cellular functions such as import and export of various substances including iron chelators (siderophores) [23]. According to the Tohama I chromosome, 80 ABC transporter components have been identified [1]. Many ABC transporter components are surface associated and are involved in virulence of pathogenic bacteria [23]. It is known that the surface associated and secreted proteins usually interact with host cells, and therefore are potential immune targets. Deletion of such genes might confer a selective advantage during infection or transmission in vaccinated population. In line with this observation, we also found several lost genes which coded for putative exported proteins.
PFGE has been shown to have best discriminatory power for the study of the epidemiology of B. pertussis. More than 400 Finnish clinical isolates collected from 1953 have been analyzed by PFGE, and altogether about 60 PFGE profiles have been identified [6,21]. One PFGE profile BpSR11 has emerged since 1999 and become predominant. The strains with BpSR11 were associated with the recent nationwide epidemic in the country. Interestingly, all the strains with BpSR11 analyzed in the present study had a lost locus (Locus 3) of 18 genes with the length of 22,700 base pairs. Among the 20 clinical strains studied, only one was found to have both gene loss and duplication. The duplicated genes were associated with the functions of cell motility, intracellular trafficking and secretion, cell wall/membrane biogenesis, and posttranslational modification, protein turnoverand chaperones. Most interesting was that a number of duplicated genes were related to flagella. Flagella are usually expressed in the Bvg 2 -phase and involved in the survival of the bacteria in the environment. In B. pertussis, the flagellar operon was considered to be inactivated due to multiple pseudogenes and IS insertions [1]. It is of interest to study if the B. pertussis strain in which flagellar genes were duplicated can express the flagella and is motile.
In this study, the oligonucleotides used for microarray were designed from the genome of the Tohama I strain [1]. We were able to clearly distinguish between the presence, absence or duplication of genes among the clinical strains studied. A drawback of microarray-based comparative genomic analysis is that it cannot detect genes that are not present in the Tohama I strain. Although the acquisition of ''new'' genetic material does not seem to be a significant source of genetic variation in B. pertussis [1,31], it is worthwhile to sequence the genome of recent B. pertussis isolate(s) and to show how representative the strain Tohama I, which is used for the production of a number of pertussis vaccines, is. Furthermore, sequencing of recent isolate(s) may identify genes acquired by B. pertussis which play a role in the persistence and resurgence of pertussis despite vaccination.
In conclusion, this microarray based on 70-mer oligonucleotides proves to be a powerful tool for comparative genomic analysis of B. pertussis strains. Our results showed that the progressive gene loss mediated by the homologous recombination between IS elements occurred in B. pertussis strains in Finland, where the vaccination against pertussis has been used for more than 50 years. The recent epidemic-causing strains showed the largest degree of gene loss compared with the vaccine strains. The high consistency in gene loss could imply the presence of antigenic determinants among lost genes and gene loss may be one strategy for B. pertussis to adapt to highly vaccinated populations.